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Saturday, September 7, 2019

Doncha just HATE LDL?

European
guidelines on lipid control advocate 'lower is better' for cholesterol levels

European Society of Cardiology

Low-density lipoprotein (LDL)
cholesterol levels should be lowered as much as possible to prevent
cardiovascular disease, especially in high and very high risk patients. That's
one of the main messages of the European Society of Cardiology (ESC) and
European Atherosclerosis Society (EAS) Guidelines on dyslipidaemias published
online today in European Heart Journal and on the ESC website.

Cardiovascular disease (CVD) is
responsible for more than four million deaths in Europe each year. Clogged
arteries, known as atherosclerotic CVD, are the main type of disease. The
guidelines provide recommendations on how to modify plasma lipid levels through
lifestyle and medication to reduce the risk of atherosclerotic CVD.

"There is now overwhelming
evidence from experimental, epidemiological, genetic studies, and randomised
clinical trials, that higher LDL cholesterol is a potent cause of heart attack
and stroke," said Professor Colin Baigent, Chairperson of the guidelines
Task Force and director of the MRC Population Health Research Unit, University
of Oxford, UK. "Lowering LDL cholesterol reduces risk irrespective of the
baseline concentration. It means that in people at very high risk of heart
attack or stroke, reducing LDL cholesterol is effective even if they have below
average starting levels."

There is no lower limit of LDL
cholesterol that is known to be unsafe. The guidelines aim to ensure that the
available drugs (statins, ezetimibe, PCSK9 inhibitors) are used as effectively
as possible to lower levels in those most at risk. It is recommended that such
patients should achieve both a target LDL cholesterol level and a minimum 50%
relative reduction.

"This is to ensure that high-
or very high-risk patients receive intensive LDL cholesterol lowering therapy
irrespective of their baseline level," said Professor Alberico L.
Catapano, Chairperson of the guidelines Task Force and professor of
pharmacology at the Department of Pharmacological and Biomolecular Sciences,
University of Milan, Italy. "Patients who are already close to their
target on current treatment will be offered additional treatment that provides
a further minimum 50% reduction."

"Statins are very well
tolerated, and true 'statin intolerance' is uncommon. Most patients can take a
statin regimen," noted Professor François Mach, Chairperson of the
guidelines Task Force and head of the Cardiology Department, Geneva University
Hospital, Switzerland. "Statins have very few side-effects. These include
an increased risk of developing diabetes, and they may rarely cause myopathy.
But the benefits of statins greatly outweigh their hazards, even among those at
low risk of atherosclerotic CVD."

However, statins are not recommended
in pre-menopausal women considering pregnancy or not using adequate
contraception. "Although these drugs have not been shown to cause fetal
malformations when unintentionally used in the first trimester of pregnancy,
women needing a statin should avoid them during any period when they might
conceive, as no formal study to address this question has been performed,"
said Prof Catapano.

The evidence for statin therapy is
more limited in patients over 75, though is still consistent with a benefit.
The guidelines advise taking level of risk, baseline LDL cholesterol, health
status, and the risk of drug interactions into account when deciding whether
statins are appropriate in those aged 75 or over.

Revisions have been made to the risk
stratification categories so that patients with atherosclerotic CVD, diabetes
with target organ damage, familial hypercholesterolaemia, and severe chronic
kidney disease are all categorised as very high-risk (and so will be offered
intensive LDL-lowering therapy). Treatment goals for a particular risk category
apply regardless of whether or not patients have had a heart attack or stroke.

Evidence since the 2016 guidelines
suggests that raised Lp(a) is a cause of atherosclerotic CVD, and patients with
genetically elevated Lp(a) can have similar lifetime risk of heart attack or
stroke as those with familial hypercholesterolaemia. Since Lp(a) is largely
genetically determined, the guidelines recommend measuring it at least once in
adulthood. "Assessment should be around 40 years of age to identify people
before they have a heart attack or stroke," said Prof Baigent.

Fish oil supplements (particularly
icosapent ethyl) are recommended, in combination with a statin, for patients
with hypertriglyceridaemia despite statin treatment. In these patients,
supplements reduce the risk of atherosclerotic CVD events, including heart
attack and stroke, by about one quarter.

The guidelines advocate a lifetime
approach to cardiovascular risk. This means that people of all ages and risk
levels should be encouraged to adopt and sustain a healthy lifestyle. "The
main requirements are healthy diet, avoidance of cigarette smoking, and regular
exercise," said Prof Mach. "There is no evidence that fish oil
supplements prevent first heart attacks and strokes, so we did not recommend
them for healthy people."

Thought for the day

You’d be forgiven if you hadn’t noticed. His verbal bombshells are louder than ever, but Donald J Trump is no longer president of the United States. By having no constructive response to any of the monumental crises now convulsing America, Trump has abdicated his office. He is not governing. He’s golfing, watching cable TV and tweeting…

In reality, Donald Trump doesn’t run the government of the United States. He doesn’t manage anything. He doesn’t organize anyone. He doesn’t administer or oversee or supervise. He doesn’t read memos. He hates meetings. He has no patience for briefings. His White House is in perpetual chaos.

Robert Reich

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